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Required/
Preferred

Bachelor's Degree

in a relevant healthcare-related field or Quality Management.

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HRTMS Job Description Management

NI-Specialist, Clinical Quality

J o b D e s c r i p t i o n

JOB INFORMATION
Effective Date:	4/25/2017
Entity:	Illinois
Job Code:	NI-2078AC
Job Title:	NI-Specialist, Clinical Quality
Exemption Status:	Exempt
JOB SUMMARY
The Clinical Quality Specialist, working with the Director of Quality, Safety and Accreditation, and the Chair of the Medical Staff Committee, coordinates and integrates the Quality Program for Medical Staff activity in the Hospital. Lead in collaboration with the Director of Quality, Safety, and Accreditation, as well as the Chair of the Medical Staff Committee, to coordinate and integrate the Quality Program for Medical Staff activities in the Hospital. Act as a key liaison between various stakeholders, ensuring effective communication and coordination to meet quality program objectives. Lead quality indicator development by monitoring quality indicators for clinical improvement activities, medical staff quality programs, and other assigned committees. Compile and analyze data to provide actionable insights that contribute to ongoing improvements in clinical quality and patient safety. Advanced knowledge in database systems to create Ongoing Professional Practice Evaluations (OPPE) and Focused Professional Practice Evaluations (FPPE) for the Credentialing Process. Ensure accuracy and thoroughness in evaluations to maintain high standards in the credentialing process. Lead educational experiences that align with the departmental philosophy, objectives, and broader Health System initiatives.

MAJOR RESPONSIBILITIES

•	Provides oversight to the Ongoing Professional Practice Evaluations (OPPE) and Focused Professional Practice Evaluations (FPPE) for Medical Staff and other accrediting body requirements. Utilizes quality data base(s) to maintain and provide necessary data for committees and teams assisting in quality control activities.
•	Oversees Medical Staff Quality and Safety Committee and subcommittees and prepares information for presentation and required follow-up. Attends medical staff meetings serving as the primary resource for quality/improvement activities.
•	Maintains technical expertise and functions as a resource, collaborating and effectively communicating Quality issues, guidelines, standards and directives with Medical staff, Nursing and other health professionals
•	Supports clinical improvement processes and CQI philosophy throughout the organization. Assists teams within the Health System with the development of indicators, data analysis, problem solving and integration of quality improvement initiatives.
•	Collaborates with Risk Management and Medical Staff office and other departments as appropriate with respect to Credentialing and Risk Management quality issues.
•	Assists with the development and revision of Quality Resource policy and procedure manuals and updates to the indicator monitoring program.

ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS.

Age Specific Competency (Clinical jobs only)
X	Non-Clinical

JOB REQUIREMENTS

Work Experience
Experience	Experience Details	Required/ Preferred

Required Skills, Knowledge, and Abilities
•	Successful completion of annual job specific competencies.
•	Ability to work with risk management and other healthcare staff.
•	Working knowledge of accrediting agency standards.
•	Excellent computer and word processing skills.
•	Advanced Excel skills, especially graphing data over time and coaching colleagues in understanding the science of improvement.
•	Excellent interpersonal skills and ability to work with colleagues at all levels under varied conditions.
•	Excellent organizational, critical-thinking, verbal and written communication skills.

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

Physical Demands
A thorough completion of this section is needed for compliance with legal standards such as the Americans with Disabilities Act. The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
Physical Demand	Continuous Over 70%	Frequent 40% - 69%	Occasional 15% - 39%	Rarely Up to 15%
Standing			X
Walking			X
Climbing				X
Bending				X
Crouching				X
Pushing / Pulling				X
Carry				X
Fine Hand / Eye Coordination		X
Color Discrimination			X
Hearing Ability		X
Lifting / Lowering 1 -15 lbs.				X
15 - 30 lbs.				X
30 - 50 lbs.				X


Over 50 lbs.	UW Health does not require, nor does it expect that its employees lift more than 50 lbs unassisted. Objects in excess of 50 lbs should be lifted or moved with mechanical means or through a team lift. Employees in patient care areas are expected to utilize mechanical lifts and adhere to the "Use of Mechanical Lifts (Liko)" policy in the Patient Services Policy and Procedure Manual.

Physical Demands
While performing the duties of this job, the associate is required to work within the selected working environments.
Physical Demands	Continuous Over 70%	Frequent 40% - 69%	Occasional 15% - 39%	Rarely Up to 15%
Concentration on Detail		X
Attention Span of 1 + Hours on a Task		X
Ability to Remember Multiple Tasks		X
Oral Communication		X
Written Communication		X

Physical Demands
Physical Demands	Continuous Over 70%	Frequent 40% - 69%	Occasional 15% - 39%	Rarely Up to 15%
Exposure to Blood and Body Fluids			X
Exposure to Toxins, Cytotoxins, Poisons				X
Exposure to Extreme Heat, Cold, Temp Fluctuations				X
Exposure to Hazardous Chemicals				X
Exposure to Radiation				X

Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.